1. Your client's name?
3. Date of Birth or Age?
4. In which state will the application be taken?
5. Amount of money to invest?
6. What type of deposit?
7. Is this Qualified or Non-Qualified Money?
8. Money is earmarked for:
RetirementImmediate IncomePass to HeirsFuneral ExpenseOther
9. If you would like to show an income, at what age should it start?
10. If showing an income stream, how long should it last?
Life OnlyLife and Ten Years GuaranteedLife and Twenty Years GuaranteedPeriod Certain for Ten YearsInterest Only
11. Additional comments or notes that may be needed to run the illustration:
12. Agent's Name? (For the Illustration)
13. Agents Phone Number? (For the Illustration)
14. Agents fax number? (Where you would like the illustration to be faxed)